Provider Demographics
NPI:1851587331
Name:MIMS FAMILY CARE HOME
Entity Type:Organization
Organization Name:MIMS FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-552-6455
Mailing Address - Street 1:6337 MIMS RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-9559
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6337 MIMS RD
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540-9559
Practice Address - Country:US
Practice Address - Phone:919-552-6455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL092045320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801930Medicaid